91

The case of Spain reflects to a marked extent the more general European tendency toward the proliferation of new institutions called on to meet social and demographic challenges. Health care in Spain has traditionally been dispersed among a host of largely autonomous agencies associated with various levels of political authority (national. provincial, or municipal.) The creation of the National Health System (SNS) as a single, albeit decentralized system, has brought important organizational changes and led to a generalized reconsideration of institutional equilibria by establishing the Governments of the Autonomous Communities as the primary interlocutors of the Ministry of Health. Also present are professional associations, labor unions, and other organizations such as NGO’s or patient’s associations. These have, with more or less success, attempted to influence the decision-making process. The present article analyzes the evolution of actor networks involved in the «governance of health» in Spain, an evolution characterized at once by strong decentralizing tendencies and by new forces of public management often bringing a reinforcement of the regulatory role of the state.